Comfort, Pain, Sleep-Rest

The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient? A) CRIES scale B) COMFORT scale C) FLACC scale D) FACES scale

A) CRIES scale

The nurse is designing a teaching plan for community members on ways to prevent chronic pain. Which information should the nurse include in this teaching plan? Select all that apply. A) Eating a healthy diet B) Obtaining adequate sleep C) Avoiding illicit drug use D) Limiting smoking to only before bedtime E) Avoiding repetitive movements

A) Eating a healthy diet B) Obtaining adequate sleep C) Avoiding illicit drug use E) Avoiding repetitive movements Lifestyle habits that predispose individuals to chronic health alterations increase an individual's risk for experiencing discomfort. Eating a healthy diet and obtaining adequate sleep can prevent the development of chronic diseases that lead to symptoms of discomfort. Using illicit drugs and smoking can cause emotional and physical withdrawal symptoms when the drug is no longer used. It is wise to not engage in smoking or illicit drug use to prevent the onset of discomfort. Repetitive movements can increase the risk for injury and fatigue, leading to discomfort.

A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of-life pain management? (Select all that apply) A) Fear of addiction B) Belief that pain is an expected part of their illness C) Inability to sleep D) Lack of support E) Inadequate pain assessment

A, B, E A) Fear of addiction B) Belief that pain is an expected part of their illness E) Inadequate pain assessment

A nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions? (Select all that apply.) A) Muscular pain B) Active bleeding C) Backache D) Menstrual discomfort E) Swollen extremity

A, C, D Muscular pain, backache, menstrual discomfort The nurse should discuss the fact that heat therapy, in the form of a heating pad or hot water bottle, is typically used for muscular pain relief, such as back pain or menstrual pain.

A charge nurse is reviewing factors that can affect a client's perception of pain with a newly licensed nurse. Which of the following should the charge nurse include? (Select all that apply) A) Stress B) Dietary practices C) Culture D) Social support E) Disease severity

A, C, E A) Stress C) Culture E) Disease severity

A nurse is evaluating a client's pain level using the PQRST mnemonic. Which of the following questions should the nurse ask to evaluate the letter "R"? A) "Can you rate your pain on a scale of 0 to10, with 0 being no pain and 10 being the worst pain you can imagine?" B) "Can you point to where you are having your pain?" C) "What does your pain feel like?" D) "What were you doing when your pain started?"

B) "Can you point to where you are having your pain?" The nurse should use the PQRST mnemonic to obtain more information about the client's pain. This question evaluates the region of the client's pain.

When developing the plan of care for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain is most effectively relieved when analgesics are administered in what matter? A) On a PRN (as needed) basis B) Conservatively C) Around the clock (ATC) D) Intramuscularly

C) Around the clock (ATC)

The nurse is preparing to assess pain level for several clients. What will the nurse assess, in addition to the client's physical experience of pain? Select all that apply. A) Religion B) Friendship C) Environment D) Psychospirituality E) Social interaction

C, D, E Environment, Psychospirituality, Social interaction Comfort is the experience of having needs for relief and ease met in four contexts: physical, psychospiritual, social, and environmental.

A nurse is monitoring a client who is 2 hr postoperative and is receiving morphine vis PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid-induced ventilatory impairment (OIVI)? (Select all that apply.) A) Bowel sounds B) Deep tendon reflexes C) Respiratory rate D) Capnography E) Oxygen saturation

C, D, E Respiratory rate, capnography, oxygen saturation

A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every 4 hr PRN. Which of the following statements by the client indicates an understanding of the instructions? A) "I can use the morphine as needed as long as I don't take it more than six times a day." B) "I will use my household teaspoon to measure the correct amount of morphine." C) "I will monitor for high blood pressure while taking the morphine." D) "I will keep the morphine bottle in a locked cabinet in my kitchen."

D) "I will keep the morphine bottle in a locked cabinet in my kitchen." Morphine is a medication that carries significant risks to others, including children, and should only be accessible and used by the client for whom it is prescribed. Storing the medication in a high cabinet prevents accidental access to the morphine by others.

A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medications following surgery. What would be a correct response by the nurse? A) "It's not a good idea to ask for pain medication regularly as it can be addictive." B) "It is better to wait until the pain gets unbearable before asking for pain medication." C) "It's natural to have to put up with pain after surgery and it will lessen in intensity in a few days." D) "Your doctor has ordered pain medications for you, which you should not be afraid to request any time you have pain."

D) "Your doctor has ordered pain medications for you, which you should not be afraid to request any time you have pain."

What is a lifestyle risk factor for fatigue? A) Chemotherapy B) Stress C) Surgery D) Inactivity

D) Inactivity Inactivity is a lifestyle risk factor for fatigue.

An older adult client recovering from prostate surgery is waking up frequently during the night. Which client statement supports the nursing diagnosis Disturbed Sleep Pattern? A) "The pain in my hips is unbearable at times." B) "I walk for half an hour after I eat breakfast." C) "I take my Zoloft as soon as I get up in the morning." D) "I have one cup of regular coffee in the morning."

A) "The pain in my hips is unbearable at times." Physical discomfort or pain, especially from osteoarthritis and focused in the hips, often disrupts the sleep of older persons.

A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include? (Select all that apply.) A) Face B) Legs C) Alert D) Circulation E) Consolability

A) Face B) Legs E) Consolability

Which most common cause of sleep deprivation in the hospital should the nurse consider when planning care? A) Fragmented sleep B) Early awakening C) Restless legs D) Sleep apnea

A) Fragmented sleep Sleep deprivation occurs with frequent interruptions of sleep because the sleeper returns to stage I rather than to the stage that was interrupted. There is a greater loss of stage III and IV non-rapid-eye-movement (NREM) sleep, which is essential for restorative sleep.

Sleep disorders mainly do what with respect to the activities of daily living? A) Interfere B) Decrease C) Change D) Increase

A) Interfere Sleep disorders can lead to disrupted activities of daily living, and so primarily interfere with such activities. They do not necessarily decrease these activities, change them, or increase them, but they do make them more difficult to accomplish.

A nurse is caring for a client who is postoperative following abdominal surgery and has a morphine PCA pump. Which of the following medications should the nurse ensure is available in case the client develops respiratory depression? A) Naloxone B) Lidocaine C) Prednisone D) Amitriptyline

A) Naloxone Naloxone is a reversal agent for respiratory depression caused by opioids. It works quickly to reverse the effects of opioids on the client's respiratory system.

A nurse is teaching staff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse make? A) "Justice allows the client the freedom of choice." B) "Justice allows the client the opportunity to be treated fairly." C) "Justice is causing no harm to the client." D) "Justice is doing good for the client."

B) "Justice allows the client the opportunity to be treated fairly." Justice requires that all clients be treated fairly in regard to their pain management regardless of age, ethnicity, or history, such as substance use disorder or limited social and economic resources. Pain relief should be available to all clients.

A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the client's knee for how long? A) 60 min B) 20 min C) 30 min D) 45 min

B) 20 min The nurse should apply heat therapy for no more 20 min at a time with at least a 20-min break after usage.

When assessing a patient receiving a continuous opioid infusion, the nurse immediately notifies the physician when the patient has: A) A respiratory rate of 10/min with normal depth B) A sedation level of 4 C) Mild confusion D) Reported constipation

B) A sedation level of 4

Which of the following is most characteristic of the clinical manifestations of sleep apnea? A) Difficulty thinking B) Difficulty breathing C) Difficulty waking up D) Difficulty controlling motor functions

B) Difficulty breathing Sleep apnea can manifest as snoring or gasping during sleep, and treatment may involve devices to assist with ventilations during sleep.

A patient complains of abdominal pain that is difficult to localize. The nurse documents this as which type of pain? A) Cutaneous B) Visceral C) Superficial D) Somatic

B) Visceral

A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC Pain Scale to determine their pain level? (Select all that apply) A) A 12-year-old client who has had an appendectomy B) A 3-year-old toddler who has a fractured femur C) A 6-day-old infant who had a surgical repair of a heart defect D) A 14-year-old client who has severe cognitive and developmental delays E) A 5-year-old preschooler who is experiencing pain during a sickle cell crisis

B, C, D, E A 3-year-old toddler who has a fractured femur, a 6-day-old infant who had a surgical repair of a heart defect, a 14-year-old client who has severe cognitive and developmental delays, a 5-year-old preschooler who is experiencing pain during a sickle cell crisis.

A client has been prescribed iron supplements to treat fatigue and a hemoglobin level of 9. What additional information should the nurse suggest to the client to help reduce feelings of fatigue associated with a low red blood cell count? Select all that apply. A) Increasing intake of ice cream B) Drinking a glass of orange juice each day C) Increasing intake of red meat D) Increasing intake of wax beans E) Increasing intake of green, leafy vegetables

B, C, E Drinking a glass of orange juice each day, Increasing intake of red meat, Increasing intake of green, leafy vegetables Iron is absorbed better when accompanied with vitamin C in foods such as orange juice. Green, leafy vegetables and red meat are good sources of iron that the client can consume in a healthy diet.

Which of the following best characterizes the sociocultural context of holistic human experience? A) Balance of physical processes B) Connection to a higher power C) Connection to others D) Equilibrium with external circumstances

C) Connection to others The sociocultural context of holistic human experience involves connection with others in society.

A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of: A) Pruritus B) Urinary retention C) Vomiting D) Respiratory depression

D) Respiratory depression

The nurse provides an in-service to peers regarding situations that can affect the comfort level of the clients on the unit. Which client statement indicates that the client's sense of well-being is negatively impacted? A) "I feel like I have no energy today." B) "I don't feel any physical pain today." C) "I was able to sleep uninterrupted last night." D) "I am so glad that playing cards takes my mind off my worries."

A) "I feel like I have no energy today." Fatigue is a lack of energy and motivation. A fatigued client is unable to focus on healing and lacks the ability to cope in stressful situations. Restful sleep, physical well-being without pain, and appropriate diversion all promote a sense of comfort for the client.

A nurse is reviewing a new prescription with a client who reports difficulty managing their chronic pain. Which of the following statements should the nurse include? A) "You should write down the pain interventions you use and your pain rating before and after." B) "You should understand that it is impossible to fix everyone's pain." C) "Your provider is best at determining whether your pain treatments are effective." D) "Your care partner should manage your pain control because you are unable."

A) "You should write down the pain interventions you use and your pain rating before and after." Keeping a pain diary or a pain log can be helpful for the client to determine if medications or treatments are helping over time.

The nurse is caring for a client who is experiencing chronic fatigue related to medication being taken for seasonal allergies. What should the nurse anticipate would most likely help this client? A) A medication change to treat seasonal allergies B) Physical therapy to promote exercise C) Acupuncture and massage D) Sleep medication to increase rest time

A) A medication change to treat seasonal allergies The nurse might expect the provider to try different dosages or different medications to try to relieve the symptoms.

Mr. Wright is recovering from abdominal surgery. When the nurse assists him to walk, she observes that he grimaces, moves stiffly, and becomes pale. She is aware that he has consistently refused his pain medication. What would be a priority nursing diagnosis for this patient? A) Acute Pain related to fear of taking prescribed postoperative medications B) Impaired Physical Mobility related to surgical procedure C) Anxiety related to outcome of surgery D) Risk for Infection related to surgical incision

A) Acute Pain related to fear of taking prescribed postoperative medications

A client is experiencing sudden-onset severe pain in the left lower quadrant of the abdomen that is rated as a 10 on a pain scale of 0-10. The client is also experiencing nausea, vomiting, and restlessness. Based on this data, the nurse concludes that the client is experiencing which phenomenon? A) Acute pain B) Chronic pain C) End-of-life pain D) Fibromyalgia pain

A) Acute pain Duration establishes the difference between acute and chronic pain. Acute pain is defined as pain that lasts only through the expected recovery period, which is usually 30 days to 6 months. Acute pain typically has a sudden onset related to injury, surgery, or illness.

A nurse is caring for a client who has a prescription for hydromorphone 1 to 2 mg IM every 4 hr as needed for a pain rating of 4 to 6 on a 0 to 10 scale. The client has never taken hydromorphone before. Which of the following actions should the nurse plan to take? A) Administer 1 mg IM. B) Request a prescription to give the medication IV instead. C) Request a prescription for a different medication. D) Administer 2 mg IM.

A) Administer 1 mg IM. When a client has a prescription that includes a range, and the client has never taken the medication previously, the nurse should administer the lowest dose to the client. If the dose is ineffective, the nurse can increase the dosage up to the maximum amount in the range prescribed by the provider.

The nurse is creating a pain management plan using the three-step approach for a client with intractable pain. Which interventions should the nurse include in this plan? Select all that apply. A) Administer a nonopioid analgesic first. B) Administer an opioid analgesic first. C) Administer a nonopioid with an opioid second. D) Administer an opioid analgesic last. E) Administer analgesics upon client request.

A) Administer a nonopioid analgesic first. C) Administer a nonopioid with an opioid second. D) Administer an opioid analgesic last. The first step in the three-step approach to pain management involves administering a nonopioid drug first. If pain is not adequately controlled with this mild intervention, clients should advance to step 2 and receive a mild opioid in combination with the same or a new nonopioid drug. If the client is still experiencing pain, the mild opioid should be replaced with a stronger opioid in step 3. Pain-relieving drugs should be given "by the clock" (every 3-6 hours) rather than on demand to maintain freedom from pain.

During a home visit with new parents, the nurse learns that a new mother is fatigued because the baby is not sleeping well. Which suggestion could the nurse make that would most help decrease this client's fatigue? A) Advise the client to alternate night feedings with the baby's father to allow each parent to rest. B) Suggest that the client ask the neighbors to babysit one night a week. C) Ask the physician for medication to restore energy. D) Increase exercise time each week to promote energy.

A) Advise the client to alternate night feedings with the baby's father to allow each parent to rest. Getting up with the newborn causes fatigue over time. If the parents take turns getting up, each parent will get a full night of rest every other day, which should help with fatigue.

An 18-month-old toddler scheduled for routine vaccinations begins to cry when placed on the examination table. The parent attempts to comfort the toddler, but nothing is effective. Which action by the nurse is the most appropriate? A) Allow the toddler to sit on the parent's lap and begin the assessment. B) Allow the toddler to stand on the floor until the crying stops. C) Ask another nurse in the office to hold the toddler because the parent is not able to control the toddler's behavior. D) Instruct the parent to hold the toddler down tightly to complete the examination.

A) Allow the toddler to sit on the parent's lap and begin the assessment. Toddlers are most comfortable when sitting with the parents. Vaccinations can be administered in this way if the parent is taught proper therapeutic holding techniques to keep everyone safe for the procedure.

A nurse is caring for a patient who is experiencing pain. For which common psychological response to pain should the nurse assess the patient? A) Experiencing fear related to loss of independence B) Withdrawing from social interactions with others C) Asking for pain medication to relieve the pain D) Verbalizing the presence of nausea

A) Experiencing fear related to loss of independence Psychological or affective responses to pain relate to feelings and emotional distress. Fear of being dependent on others and loss of self-control are psychological responses to pain.

The nurse is conducting a clinic visit with a mother and an adolescent client. Both the mother and the adolescent report that the adolescent is not able to sleep until late at night and then wakes up too late in the morning. This has caused the adolescent to be late for school several times. The mother states, "I don't know what to do." Which response by the nurse is the most appropriate? A) Inform her that several techniques can potentially help correct this problem. B) Recommend a polysomnography (PSG). C) Indicate that this is simply a normal change of the body's internal clock associated with puberty, and it will work itself out. D) Ask about other medical conditions because the adolescent's sleep patterns indicate the onset of a chronic illness.

A) Inform her that several techniques can potentially help correct this problem. Adolescents experience changes in the body's internal clock associated with puberty that in some adolescents cause a delay in melatonin release each night; the result is delayed sleep phase syndrome. Signs of delayed sleep phase syndrome include an inability to fall asleep and wake up at the desired time. The use of sleep hygiene, sleep restriction therapy, and relaxation techniques can be beneficial in the treatment of this syndrome.

A patient is experiencing anxiety. Which aspect of sleep should the nurse expect primarily will be affected as a result of the anxiety? A) Onset B) Depth C) Stage II D) Duration

A) Onset Anxiety increases norepinephrine blood levels through stimulation of the sympathetic nervous system, which results in prolonged sleep onset.

Which of the following statements best characterizes risk for injury as it relates to pain? A) Risk for injury is an external risk factor for pain. B) It is difficult to predict what might pose a risk for injury. C) Risk for injury can be decreased by living a healthy lifestyle. D) Precautions against risk for injury are rarely successful in preventing injury.

A) Risk for injury is an external risk factor for pain. External risk factors for pain, such as the risk for injury, can be decreased by safety precautions such as wearing a seat belt or helmet.

A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of pain? A) The client is diaphoretic. B) The client is experiencing stabbing pain. C) The client is nauseated. D) The client states feeling dizzy.

A) The client is diaphoretic. The nurse should identify that sweating is an objective manifestation of pain. Objective data is information the nurse can gather by using their five senses. Sweating can be visually noticed by the nurse.

Which concept should the nurse consider when assessing a patient's pain? A) The expression of pain is not always congruent with the pain experienced. B) Pain medication can significantly increase a patient's pain tolerance. C) The majority of cultures value the concept of suffering in silence. D) Most people experience approximately the same pain tolerance.

A) The expression of pain is not always congruent with the pain experienced. An obvious response to pain is not always apparent because psychosociocultural factors may dictate behavior. Fear of the treatment for pain, lack of validation, acceptance of pain as punishment for previous behavior, and the need to be strong, courageous, or uncomplaining are factors that influence behavioral responses to pain.

A pregnant client experiencing fatigue describes her typical diet as consisting of fast food such as burgers and fries for lunch, takeout from Chinese or Mexican restaurants for dinner, and orange juice or a fruit smoothie in the morning. What is the problem with this diet? A) The fast food because it's likely high in fat. B) The takeout food might be saucy and heavy. C) The burgers contain red meat. D) The fruit smoothies are processed.

A) The fast food because it's likely high in fat. Fatigue in expectant mothers is often caused by iron-deficiency anemia. Expectant mothers should be encouraged to eat more protein, including lean meats and beans, and to take an iron supplement. Vitamin C increases iron absorption, so pregnant women should be encouraged to eat fruits and vegetables that contain high amounts of vitamin C. The fast food would be a problem because it's fatty, not because of the red meat content.

A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include? (Select all that apply.) A) Transcutaneous electronic stimulating unit (TENS unit) B) Distraction techniques C) Massage D) Acupuncture E) Cold therapy

A) Transcutaneous electronic stimulating unit (TENS unit) C) Massage D) Acupuncture E) Cold therapy

The nurse is caring for a pediatric client with a surgical wound. The wound is red with purulent drainage and is causing discomfort for the client. Which diagnostic test will determine if the discomfort of the wound is caused by an infection? A) White blood cell count B) Hematocrit measurement C) Urine analysis D) X-rays of the site

A) White blood cell count There are a few tests that can help the medical team determine the source of the client's discomfort. In this case, a white blood cell count will determine if the discomfort is being caused by an infection.

A 12-year-old boy is experiencing nocturnal enuresis. Which strategies should the nurse explore with the boy and his parents? Select all that apply. A) Limiting fluid intake after dinner B) Voiding immediately before going to bed C) Eliminating caffeinated beverages from the diet D) Thinking about waking up dry when going to bed at night E) Having the boy change his own bed linens when he wets the bed

A, B, C, D A) Limiting fluid intake after dinner- Limiting fluid intake after dinner reduces the amount of urine production while asleep. B) Voiding immediately before going to bed- Voiding empties the bladder and makes room for urine produced during the night. C) Eliminating caffeinated beverages from the diet- Caffeine irritates the mucous membranes of the urinary system and stimulates the need to void. D) Thinking about waking up dry when going to bed at night- Positive imagery supports self-esteem and may become a self-fulfilling prophesy.

A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort? (Select all that apply.) A) Grimacing B) Restlessness C) Elevated temperature D) Increased diaphoresis E) Bradycardia

A, B, D Grimacing, restlessness, increased diaphoresis Clients who have cognitive impairment or communication challenges (e.g., expressive aphasia) require careful nursing assessment. The client might not report pain effectively, and the nurse should look for behaviors that suggest pain is present such as guarding, grimacing, restlessness, and other behavioral changes.

A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients' pain control? (Select all that apply) A) Consider each client's cultural preferences. B) Determine the effectiveness of nonpharmacological strategies. C) Record the clients' subjective reports rather than the nurse's objective observations. D) Recognize that older adult clients over-report their pain level. E) Use a pain scale specific to each client's cognitive abilities.

A, B, E A) Consider each client's cultural preferences. B) Determine the effectiveness of nonpharmacological strategies. E) Use a pain scale specific to each client's cognitive abilities.

A participant in a seminar given by a nurse asks for information about lifestyle situations that might contribute to chronic fatigue. Which examples might the nurse identify in response to this request? Select all that apply. A) Thyroid problems B) Chronic back pain C) Marijuana use D) Vigorous exercise three times a week E) Swimming after a meal

A, B,C Thyroid problems, Chronic back pain, Marijuana use Fatigue is a symptom that needs investigating. Some risk factors for fatigue are hyper- or hypothyroidism, use of illicit drugs such as marijuana, and chronic pain.

A patient is having difficulty sleeping and may be experiencing shortened non-rapid- eye movement (NREM) sleep. Which patient assessments support this conclusion? Select all that apply. A) Decreased pain tolerance B) Inability to concentrate C) Excessive sleepiness D) Irritability E) Confusion

A, C A)Decreased pain tolerance- An increased sensitivity to pain is associated with disturbed non-rapid- eye-movement (NREM) sleep. During NREM sleep the body is engaged in restoring physiological properties of the body. C) Excessive sleepiness- During NREM sleep the parasympathetic nervous system dominates and the vital signs and metabolic rate are low; also, growth hormone is consistently secreted, which provides for anabolism. Shortened NREM sleep decreases these restorative processes, resulting in fatigue, lethargy, and excessive sleepiness.

A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information? (Select all that apply) A) "A client's religious beliefs might affect the way they respond to pain." B) "Herbal therapies are not permitted for a client receiving prescription pain medication." C) "The client's past pain experiences are not related to their current pain and pain management." D) "If a client can rate their pain using a numeric pain scale, there is no need to note nonverbal findings." "E) Pain control might be harder to achieve if the nurse and client speak different primary languages."

A, C, E The nurse should be aware of factors that could inhibit communication with the client and prevent pain control, such as differences in ethnic backgrounds or religious beliefs. The client's past pain experiences are not related to their current pain and pain management. The nurse should be aware of factors that could inhibit communication with the client and prevent pain control, such as language barriers or educational differences.

One of the most common distinctions of pain is whether it is acute or chronic. Which examples describe chronic pain? Select all that apply. A) A patient is receiving chemotherapy for bladder cancer. B) An adolescent is admitted to the hospital for an appendectomy. C) A patient is experiencing a ruptured aneurysm. D) A patient who has fibromyalgia requests pain medication. E) A patient has back pain related to an accident that occurred last year. F) A patient is experiencing pain from second-degree burns

A, D, E A patient is receiving chemotherapy for bladder cancer, a patient who has fibromyalgia requests pain medication, a patient has back pain related to an accident that occurred last year.

A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include? (Select all that apply.) A) "You can be taught how to use TENS therapy at home." B) "We will insert very small sterile needles into your skin to block your pain." C) "This therapy may result in you having some temporary bruising at the site of application." D) "The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas." E) "We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy."

A, D, E TENS therapy can be provided by the nurse or the client can be taught to use the TENS unit and self-administer in the home setting. These low-voltage electrical impulses reduce the nervous system's ability to transmit pain from the area of application to the brain. In addition, these impulses stimulate the body to produce endorphins, which also assist in relieving pain. The intensity, pulse rate, and duration of each pulse of treatment with TENS therapy can be adjusted by the nurse or the client.

The nurse is reviewing the admission orders for an older adult client who is being admitted for a hysterectomy. The client, who has been diagnosed as having uterine cancer, has chronic pain caused by arthritis. The healthcare provider has prescribed long-acting oral narcotic medication to be administered every 4 hours. What should the nurse do when providing the medication to the client? A) Administer the medication if the client requests it. B) Administer the medication every 4 hours around the clock. C) Consult the provider to order intravenous pain medication. D) Administer the medication sparingly to avoid narcotic addiction.

B) Administer the medication every 4 hours around the clock. Administer analgesics as prescribed. Analgesics should be administered around the clock or by self-administration with a patient-controlled analgesic (PCA) pump to keep the pain from becoming severe. In this case, the nurse should follow the prescribed administration plan of every 4 hours around the clock.

A toddler being prepared for a lumbar puncture begins to cry when carried into the treatment room by the mother. Which nursing diagnosis is most appropriate for the client at this time? A) Knowledge Deficient of the procedure B) Anxiety related to anticipated painful procedure C) Fear related to the unfamiliar environment D) Ineffective Coping related to an invasive procedure

B) Anxiety related to anticipated painful procedure The child associates the treatment room with a painful procedure, and the reaction to entering the treatment room is based on anticipation of repeat discomfort. The child's behavior is appropriate for coping in a child of this age.

The nurse is preparing to assess a 1-year-old client for signs of discomfort. When conducting the assessment, which action by the nurse is the most appropriate? A) Asking the client to rate the pain on a scale of 0-10 during the assessment process B) Asking the parent to hold the client in the lap during the assessment process C) Reading a book to the client during the assessment process D) Recommending that the parent leave the room during the assessment process

B) Asking the parent to hold the client in the lap during the assessment process Children may be fearful of physical assessment. To promote comfort, allow the child to sit on the parent's or guardian's lap during the assessment process, rather than asking the parent to leave the room.

Which is the appropriate patient outcome for an adult who has disturbed sleep because of nocturia? A) Report fewer early morning awakenings because of a wet bed. B) Demonstrate a reduction in nighttime bathroom visits. C) Resume sleeping immediately after voiding. D) Use an incontinence device at night.

B) Demonstrate a reduction in nighttime bathroom visits. Demonstrating a reduction in night- time bathroom visits is an appropriate outcome for nocturia, which is voluntary urination during the night.

An adult client diagnosed with sleep apnea has been prescribed a continuous positive airway pressure (CPAP) machine as treatment. The nurse is instructing the client on how to use the machine. Which instruction least relates to ensuring the patient's comfort with the device? A) Use a properly sized mask with the straps tight. B) Instruct the client to wear the mask with air pressure while sleeping. C) Show how to adjust the pressure to reduce difficulty exhaling. D) Demonstrate relaxation techniques to reduce a claustrophobic feeling when wearing the mask.

B) Instruct the client to wear the mask with air pressure while sleeping. Wearing the right size mask and keeping the straps tight, doing relaxation exercises to reduce the claustrophobic feelings caused by wearing the mask, reducing the difficulty of exhalation by properly adjusting pressure may all help safeguard the patient's comfort with the CPAP device, but wearing the mask with air pressure while sleeping is simply the general way the device should be used and doesn't make any special allowances for the comfort of the patient.

Which is the most important nursing intervention that supports a patient's ability to sleep in the hospital setting? A) Providing an extra blanket B) Limiting unnecessary noise on the unit C) Shutting off lights in the patient's room D) Pulling curtains around the patient's bed at night

B) Limiting unnecessary noise on the unit Noise is a serious deterrent to sleep in a hospital. The nurse should limit environmental noise (e.g., distributing fluids, providing treatments, rolling drug and linen carts) and staff communication noise.

The nurse is caring for a client who is experiencing acute chest pain that is rated as a 9 on a 0 to 10 pain scale. Based on this data, which medication does the nurse expect to administer? A) Acetaminophen B) Morphine C) Ibuprofen D) Naproxen

B) Morphine Acute pain is often treated with an opioid such as morphine. Morphine is often used to treat chest pain that is associated with a myocardial infarction. Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain, not acute chest pain.

A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to assess the client's pain and administer prescribed pain medication. Which of the following can the nurse be charged with? A) Malpractice B) Negligence C) Nonmaleficence D) Beneficence

B) Negligence Negligence means failure to perform in a manner that a reasonable person would have. By failing to assess the client's pain and administer the client's pain medication, the nurse was negligent.

An 8-year-old female client complains of chronic fatigue that has persisted for several months despite an adequate amount of sleep each night. The nurse plans the care based on a nursing diagnosis of Fatigue. What intervention is the nurse most likely to try first? A) Recommend a sleep study. B) Recommend a healthy and well-balanced diet with adequate water intake. C) Recommend that the client's parents keep a journal of her activities and sleep patterns. D) Recommend cognitive-behavioral therapy.

B) Recommend a healthy and well-balanced diet with adequate water intake. If the client appears to be getting an adequate amount of sleep each night, then ensuring the client is eating a proper diet would be the first response to fatigue.

A patient is experiencing discomfort associated with gastroesophageal reflux. In which position should the nurse teach the patient to sleep? A) Right lateral B) Semi-Fowler C) Prone D) Sims

B) Semi-Fowler Gastric secretions increase during rapid-eye-movement (REM) sleep. The semi-Fowler position limits gastroesophageal reflux because gravity allows the abdominal organs to drop, which reduces pressure on the stomach and results in less stomach contents flowing upward into the esophagus.

What word best describes fatigue from culture shock? A) Linguistic B) Temporary C) Geographical D) Mild

B) Temporary Culture shock involves adjustment to changes in culture, and so should be temporary in most cases. Differences between cultures may include a number of small changes, which build over time to cause physical and mental fatigue that should decrease the longer the individual lives within the new culture.

The nurse is assessing a client for a sleep-rest disorder. Which client behavior is most indicative of such a disorder? A) The client answers history questions in detail. B) The client expresses impatience after two or three questions and insists that the nurse hurry up and finish. C) The client expresses a concern about the privacy of the information he reveals. D) The client cannot answer definitely whether he sleeps in strange positions.

B) The client expresses impatience after two or three questions and insists that the nurse hurry up and finish. Expressing impatience after just two or three questions is indicative of irritability, which could be a sign of sleep deprivation from a sleep-rest disorder

Which client is exhibiting hypersomnia? A) The client only gets about 5 or 6 hours of sleep each night. B) The client gets roughly 8 hours of sleep each night but can't stay awake during the day. C) The client consistently has trouble getting to sleep and often lies awake for hours after bedtime. D) The client experiences repetitive involuntary leg movements that interfere with sleep.

B) The client gets roughly 8 hours of sleep each night but can't stay awake during the day. Hypersomnia is a condition of getting enough sleep at night but still exhibiting daytime drowsiness.

An adult female client is diagnosed with chronic fatigue syndrome. What statement best accompanies the diagnosis? A) Continued bed rest will relieve the condition. B) The client's physician has ruled out an obvious cause for the fatigue. C) The client is suffering complications from a severe stress reaction. D) The client needs a rigorous exercise regimen.

B) The client's physician has ruled out an obvious cause for the fatigue. Chronic fatigue syndrome occurs when an individual experiences severe tiredness that lasts more than 6 months, is not caused by a primary condition, and is not relieved by stress reduction. Because this syndrome is not caused by a primary condition and lasts for at least half a year before it is diagnosed, the physician will have ruled out an obvious cause for the fatigue by this point.

A client who has multiple sclerosis is complaining of fatigue. In recommending an exercise program to this client, what is the most likely factor the nurse will need to consider other than physician approval? A) Complementary dietary recommendations B) The intensity of the workout C) Complementary therapy recommendations D) Pharmacologic therapy

B) The intensity of the workout Clients who report persistent fatigue should be encouraged to begin a physician-approved mild to moderate exercise regimen.

Which of the following triggers pain? A) The central nervous system B) The peripheral nervous system C) The musculoskeletal system D) The cardiovascular system

B) The peripheral nervous system Pain is triggered by the peripheral nervous system, which lies outside the brain and spinal cord of the central nervous system and does not involve the musculoskeletal or cardiovascular systems.

Which of the following statements best describes the therapeutic approach to acute and chronic pain, fatigue, fibromyalgia, and sleep disorders? A) Therapy is primarily psychosocial in nature. B) Therapy involves both pharmacologic and nonpharmacologic approaches. C) Therapy is essentially physiologically focused. D) Therapy mostly involves the client avoiding risk behaviors.

B) Therapy involves both pharmacologic and nonpharmacologic approaches. For all of these conditions, therapy involves both pharmacologic and nonpharmacologic approaches. Therapy for these conditions is both physiological and psychosocial, addressing all components of client's conditions.

A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? Select all that apply. A) Pain is whatever the physician treating the pain says it is. B) Pain exists whenever the person experiencing it says it exists. C) Pain is an emotional and sensory reaction to tissue damage. D) Pain is a simple, universal, and easy-to-describe phenomenon. E) Pain that occurs without a known cause is psychological in nature. F) Pain is classified by duration, location, source, transmission, and etiology.

B, C, D, E, F Pain exists whenever the person experiencing it says it exists, pain is an emotional and sensory reaction to tissue damage, pain is a simple, universal, and easy-to-describe phenomenon, pain that occurs without a known cause is psychological in nature, pain is classified by duration, location, source, transmission, and etiology.

During an assessment, an adolescent reports: "I get up at 6 a.m., I attend early-morning band classes three times each week, I play sports for 2 hours each day after school, and homework takes me 3 hours each night. I always feel tired." Based on these data, which question will the nurse ask while continuing the client's history? A) "Do you think you are involved in too many activities?" B) "Do you consume foods high in iron such as red meat and green, leafy vegetables?" C) "How many hours of sleep do you get each night?" D) "Have you considered talking with your teachers about decreasing your homework?"

C) "How many hours of sleep do you get each night?" The data in this scenario reveal very little time for sleep; therefore, the history should focus on sleep patterns, not diet.

A client who has been undergoing treatment for chronic back pain has been considering various over-the-counter nonopioids to manage the pain. The nurse has assessed the client's needs and discussed the use of available methods with the client. Which client statement indicates the need for further instruction? A) "Nonopioid pain medications can have serious side effects I need to consider and watch for carefully." B) "I should not take a higher than recommended dose because the beneficial effect isn't likely to be higher with a higher dose." C) "I may use these medications for as long as I think they are necessary." D) "I may use both opioid and nonopioid medications together, especially to relieve severe pain."

C) "I may use these medications for as long as I think they are necessary." Over-the-counter (OTC) nonopioids are associated with severe side effects, especially when taken long term. NSAIDs can produce gastrointestinal (GI) toxicity and prolong bleeding times, and acetaminophen can produce liver and kidney toxicity. Nonopioids have a ceiling effect, so taking a higher dose will not produce a greater analgesic effect. While nonopioids are rarely effective alone for severe pain, they may produce a synergistic effect to relieve pain when combined with an opioid.

A nurse is providing end-of-life care for a client who is unresponsive and near death. The client's family asks the nurse about managing the client's pain. Which of the following statements should the nurse make to the client's family? A) "Your family member will not require pain medication." B) "Your family member can inform the provider about their decision for pain management." C) "Your family member has the right to receive effective pain management." D) "Your family member will not be able to tolerate the effects of pain medications."

C) "Your family member has the right to receive effective pain management." According to the American Society for Pain Management Nursing and the Hospice and Palliative Nurses Association position statement, end-of-life effective pain management is a basic human right. Clients who are receiving end-of-life care should receive special consideration for pain management.

A nurse is evaluating a group of clients who are experiencing pain. Which of the following clients should the nurse identify as experiencing neuropathic pain? A) A client who has osteoarthritis and reports difficulty ambulating for the past 6 months B) A client who had surgery to repair a fractured tibia and reports incisional pain C) A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury D) A hospice client who has prostate cancer and reports pelvic pain

C) A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury Neuropathic pain is often referred to as nerve pain and arises from the somatosensory system. Neuropathic pain includes diabetic neuropathy, phantom limb pain, and pain associated with a spinal cord injury. Neuropathic pain is frequently described as intense, shooting, or burning.

Which client is most likely to reject attempts at comfort? A) An infant crying B) A school-age child with abdominal pain who is anxious about a procedure C) An adolescent with a sleep disorder who doesn't want his parents to be near him D) An older adult with end-stage renal disease

C) An adolescent with a sleep disorder who doesn't want his parents to be near him Adolescents may respond to treatment and comfort better if you interact with them as adults rather than as children. Some adolescents may reject any offer of comfort, and an adolescent with a sleep disorder who has displayed antagonism toward his parents' presence is probably irritable from his condition and may immediately reject attempts at comfort, at least at first.

A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor-vehicle crash. In which way should the nurse categorize this client's pain? A) Cancer pain B) Acute pain C) Chronic pain D) Neuropathic pain

C) Chronic pain Chronic pain is pain that has been present usually for 3 to 6 months or longer after the injury or damage has healed. Examples of chronic pain are arthritis pain or pain from a back injury. Chronic pain can physically and emotionally debilitate a client.

A nurse is caring for an older adult client who has a cognitive impairment and is postoperative. Which of the following actions should the nurse take? A) Use the Crying, Requires Oxygen, Increases Vital Signs, Expression, Sleeplessness (CRIES) pain scale. B) Reassure family members that older adult clients have a decreased ability to sense pain. C) Evaluate the client for pain by observing their behavior. D) Assign a pain scale number based on the FACES pain scale.

C) Evaluate the client for pain by observing their behavior. Clients who have cognitive impairment might be unable to appropriately report their pain. The nurse should observe for behaviors that suggest pain is present such as guarding, grimacing, restlessness, and other behavioral changes.

A patient has a history of severe chronic pain. Which is the most important intervention associated with providing nursing care to this patient? A) Asking what is an acceptable level of pain B) Providing interventions that do not precipitate pain C) Focusing on pain management intervention before pain is excessive D) Determining the level of function that can be performed without pain

C) Focusing on pain management intervention before pain is excessive Administration of analgesics around the clock (ATC administration) at regularly scheduled intervals or by long-acting controlled-release transdermal patches maintains therapeutic blood levels of analgesics, which limit pain at levels of comfort acceptable to patients.

Which of the following is a pharmacologic therapy for acute pain? A) Antidepressants B) Muscle relaxants C) Opioid analgesics D) Stimulants

C) Opioid analgesics Pharmacologic pain management for acute pain involves opioid analgesics, nonopioid analgesics, or nonsteroidal anti-inflammatory drugs (NSAIDs). It does not involve antidepressants, stimulants, or muscle relaxants.

A nurse is caring for a patient who is diagnosed with narcolepsy. Which is the most serious consequence of this disorder? A) Inability to provide self-care B) Impaired thought processes C) Potential for injury D) Excessive fatigue

C) Potential for injury Narcolepsy is excessive sleepiness in the daytime that can cause a person to fall asleep uncontrollably at inappropriate times (sleep attack) and result in physical harm to self or others.

What is the relationship between a full opioid agonist and the ceiling effect? A) A full opioid agonist produces few withdrawal symptoms when the drug's effects plateau and the client begins easing off the drug. B) A client may use a full opioid agonist as much or as little as necessary to control chronic pain with no ill effects. C) Side effects may limit a full opioid agonist's use but not a plateau in the beneficial effects it produces. D) At some point, a full opioid agonist's side effects cease to increase in potency, but the pain-relieving effect continues to increase.

C) Side effects may limit a full opioid agonist's use but not a plateau in the beneficial effects it produces. Full opioid agonists do not have a ceiling effect. Therefore, full opioid agonists can be given in increasing doses until pain is relieved or side effects become intolerable.

A client with a history of insomnia is scheduled for a polysomnogram that requires an overnight stay in a sleep laboratory. The test will not include audio and video equipment. It will monitor the client's blood oxygen levels, heart rate, breathing, and eye and leg movements, and it will use an electroencephalogram to monitor brain waves. What disorder is least likely to be identified in this test? A) Periodic limb movement disorder B) Sleep apnea C) Sleep talking D) Restless leg syndrome

C) Sleep talking Heart rate, breathing, and blood oxygen levels as well as audio monitoring can detect snoring and breathing changes that suggest sleep apnea. The monitoring of leg movements detects periodic limb movement disorder and restless leg syndrome. Audio and video equipment can also detect parasomnias such as sleep talking, but because such equipment is not being used in this case, the study is least likely to identify this disorder.

What most determines the effectiveness of pharmacologic therapy for fatigue? A) The patient's attitude toward taking medication B) The length of time the patient has been fatigued C) The appropriateness to the patient's condition D) The patient's commitment to complementary therapies

C) The appropriateness to the patient's condition Pharmacologic therapy depends on the cause of fatigue. To be effective, the pharmacologic therapy must be tailored to the client's specific condition.

Which of the following statements best describes the body's adaptation to pain? A) The worse pain becomes, the more obvious it is. B) Once the body adapts to pain, its detrimental effects cease. C) The observation of pain's effects may become more difficult. D) The body's sympathetic response increases.

C) The observation of pain's effects may become more difficult. As the body adapts to pain, visible and physiological symptoms of pain may be harder to detect. The sympathetic response returns to baseline levels unless the client experiences breakthrough pain, and some visible signs of pain, such as crying, cease. Pain fibers may become sensitized so that the intensity and perception of pain increase over time.

A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at greatest risk for respiratory depression? A) A client who has chronic pain and recently started taking paroxetine B) A client who has cancer and has taken oxycodone PRN for several months C) A client who has been accidentally taking twice the amount of prednisone as prescribed D) A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN

D) A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN Use of an opioid medication can decrease the respiratory rate, and the first 4 hr postoperative are when the client is at highest risk for surgical complications. Therefore, the nurse should identify that the client who had surgery 3 hr ago and is receiving IV hydromorphone is at greatest risk for respiratory depression.

A nurse is planning to teach coworkers about the legal and ethical principles used with pain management. Which of the following examples should the nurse include as an example of autonomy? A) A nurse allows a client to wait longer for their pain medication than other clients. B) A nurse does not properly clean a vial of pain medication prior to withdrawing medication from the vial, which results in the client contracting an infection. C) A nurse administers scheduled pain medication and provides therapeutic distraction techniques for a client in pain. D) A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.

D) A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief. This is an example of autonomy. The nurse is providing the client their right of self-determination by permitting the client an ability to make an informed decision.

A patient who had a total abdominal hysterectomy two days ago reports abdominal pain at level 5 on a 0-to-10 pain scale. After assessing the pain further, which should the nurse do first? A) Reposition the patient. B) Offer a relaxing back rub. C) Use distraction techniques. D) Administer the prescribed analgesic.

D) Administer the prescribed analgesic. Major abdominal surgery involves extensive manipulation of internal organs and a large abdominal incision that require adequate pharmacological intervention to provide relief from pain.

A patient requests pain medication for severe pain. Which should the nurse do first when responding to this patient's request? A) Use distraction to minimize the patient's perception of pain. B) Place the patient in the most comfortable position possible. C) Administer pain medication to the patient quickly. D) Assess the various aspects of the patient's pain.

D) Assess the various aspects of the patient's pain. All the factors that affect the pain experience should be assessed, including location, intensity, quality, duration, pattern, aggravating and alleviating factors, and physical, behavioral, and attitudinal responses. Assessment must precede intervention.

A preschool-age client's IV has infiltrated and must be restarted immediately for medication administration. There is no time for placing local anesthetic cream on the skin to decrease the pain associated with the procedure. Which complementary therapy would be most helpful when placing the IV for this pediatric client? A) Moderate sedation B) Restraint using a "mummy wrap" C) Anesthesia D) Distraction using bubbles

D) Distraction using bubbles Complementary therapies—especially guided imagery, relaxation techniques, and distraction—can reduce the anxiety associated with the anticipation of the procedure. Playing games such as blowing bubbles would provide distraction for this pediatric client and be a valid nursing intervention.

A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. Fifteen minutes after receiving the dose, the client reports to the nurse their pain is still a 7 and has not changed. Which of the following actions should the nurse take? A) Administer another 5-mg dose of the oral opioid now. B) Administer 10 mg of oxycodone every 2 hr. C) Inform the provider that the client's pain medication is not effective. D) Offer to assist the client with nonpharmacological relief strategies.

D) Offer to assist the client with nonpharmacological relief strategies. The oxycodone would not have had time to peak and to be effective after 15 min. The nurse should offer to assist the client with nonpharmacological pain relief strategies until the medication has had time to work. Oral oxycodone peak effects should be noted 60 to 90 min after administration.

What is an example of chronic pain? A) Pain that precedes injury B) Pain that follows injury and ends when healing is complete C) Pain that is felt during injury and immediately after D) Pain that outlasts the healing process

D) Pain that outlasts the healing process Chronic pain is pain that lasts beyond the expected time of healing, usually for at least 6 months; it does not always have a known cause. Pain can range from mild to severe, and autonomic responses decrease over time as the body adapts to the persistent pain impulses. Chronic pain does not precede injury, nor does it subside immediately after injury, and it may not be related to an injury. It does not end when healing is complete.

Which of the following statements describes all pain? A) Pain is the result of tissue damage. B) Pain's effects are primarily physiological, not mental or emotional. C) Pain can be localized to a particular area of the body. D) Pain's effects can be verbalized.

D) Pain's effects can be verbalized. Pain can be described by the client, and so all pain can be verbalized. It may be the result of tissue damage or a warning of the potential for damage.

A female patient who is having a myocardial infarction complains of pain that is situated in her jaw. The nurse documents this as what type of pain? A) Transient pain B) Superficial pain C) Phantom pain D) Referred pain

D) Referred pain

A client with clinical depression asks the nurse for suggestions on how to improve the quality of sleep. The client often drinks a glass of wine before bedtime to help sleep. The client falls asleep quickly but then wakes up an hour or so later and often feels anxious. A period of wakefulness follows, often lasting several hours. Which of the following planning goals would be least appropriate for this client? A) Avoid the use of alcohol late in the evening. B) Reduce or remove environmental distractions from the bedroom. C) Maintain a consistent bedtime. D) Report decreased snoring.

D) Report decreased snoring. For this client, avoiding the use of alcohol late in the evening would definitely be a worthwhile goal, as well as ensuring an environment and a routine conducive to sleep

A client reports feeling tired and not refreshed after sleeping. The client also tells the nurse that family members have been making comments about the client's loud snoring at night. What should the nurse suspect as being the cause of this client's fatigue? A) Insomnia B) Depression C) Thyroid disorder D) Sleep apnea

D) Sleep apnea The client is snoring at home, which could indicate obstructive sleep apnea.

A nurse is planning a teaching program for a patient with a diagnosis of obstructive sleep apnea. Which should the nurse plan to discuss with this patient? A) Using the ordered device that supports airway patency B) Placing two pillows under the head when sleeping C) Requesting a sedative to promote sleep D) Sleeping in the supine position

D) Sleeping in the supine position A continuous positive airway pressure (CPAP) device worn when sleeping keeps the upper airway patent by maintaining an open pathway that facilitates gas exchange.

The nurse is preparing to assess comfort for several clients. If the nurse, in addition to assessing the client's physical experience of pain, assesses whether the client has a present and reliable personal support network, then the nurse is assessing which context of holistic human experience during this process? A) Transcendence B) Environmental C) Psychospiritual D) Sociocultural

D) Sociocultural Comfort is the experience of having needs for relief and ease met in four contexts: physical, psychospiritual, sociocultural, and environmental. Sociocultural comfort is related to family and social relationships, which a personal support network would exemplify.

What primarily differentiates lack of sleep due to a sleep disorder from lack of sleep due to another developing condition? A) The length of sleep B) The quality of sleep C) The symptoms of lack of sleep D) The cause for the lack of sleep

D) The cause for the lack of sleep The etiology, or cause, of the lack of sleep will differ depending on whether the condition is because of a sleep disorder or another developing condition. However, the length of sleep, quality of sleep, and symptoms related to the lack of sleep may not differ.

A resident in an assisted-living facility is restless most nights and sits in the lounge area reading. When questioned, the resident reports suffering from insomnia. What should the nurse expect as a likely outcome if the resident continues with this pattern of sleep? A) Sleep paralysis B) Onset of cardiac dysfunction C) Onset of new underdiagnosed health problems D) The client's activities during the day may be hindered by these episodes.

D) The client's activities during the day may be hindered by these episodes. Insomnia is defined as an inability to fall asleep or stay asleep on most nights for over a month. The individual experiencing insomnia is at risk for daytime drowsiness and may experience cognitive deficits, fatigue, and irritability, all of which can hinder the client's activities during the day.

An older adult client is talking with the nurse about sleep problems. Which fact regarding sleep should the nurse teach this client? A) All elderly individuals experience disrupted sleep and depression. B) The need for sleep decreases with age. C) Sleep problems signal the onset of other developing medical conditions. D) The elderly do not experience as much deep sleep as a younger person.

D) The elderly do not experience as much deep sleep as a younger person. Starting at age 20, there is a reduction in stages 3 and 4 NREM sleep and in REM sleep, which is the deepest sleep. This reduction in deep sleep progresses with aging.